GRACE Application Forms

Application for Cancer Patient Funds

 Printable Directions for Completing Packet

Application Form

Diagnosis Verification Form

Authorization for Disclosure of Health Information

  1. Complete the Application Form(All areas must be completed except those marked Grace Rep. Please give as much information as possible. Please sign and date on line marked “Recipient”.)
  2. Complete the Authorization for Disclosure of Health InformationThis form must be filled out by the applicant before seeing your doctor. The doctor must see this form to verify your diagnosis.
  3. Complete the Diagnosis Verification FormThis form must be completed by your doctor.
  4. All three forms listed above must be returned to the G.R.A.C.E., Inc. board to have your request acted upon. The G.R.A.C.E. board meets the second Tuesday of every month.
  5. The G.R.A.C.E office is open every Wednesday from 10:00 a.m. – 2:00 p.m.
    (Please call ahead, as times are subject to change.)

 Ambassador Nomination

Ambassador Nomination Application Form

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